Factors Associated with Interventions after Laser Peripheral Iridotomy for Primary Angle-Closure Spectrum Diagnoses.

PURPOSE: To assess factors associated with receipt of subsequent medical, laser, or surgical interventions after laser peripheral iridotomy (LPI). DESIGN: Retrospective review. PARTICIPANTS: A total of 1271 eyes in 692 subjects with narrow angles (NAs) that were treated with LPI. METHODS: Demographic and clinical factors associated with primary angle-closure (PAC) or PAC glaucoma (PACG) versus PAC suspect (PACS) diagnosis and use of glaucoma medications at the time of LPI, as well as factors predictive of subsequent addition of glaucoma medications, and receipt of selective laser trabeculoplasty (SLT), cataract surgery, and glaucoma surgery were assessed using logistic regression with generalized estimating equations. Kaplan-Meier curves and Cox proportional-hazards regression analysis were used to assess baseline factors affecting the time to SLT, cataract surgery, or glaucoma surgery. MAIN OUTCOME MEASURES: Diagnosis of PAC/PACG and medical, laser, or surgical interventions after LPI. RESULTS: African Americans (odds ratio [OR], 2.12; P < 0.001) were significantly more likely than whites to have PAC/PACG than PACS and to already be taking glaucoma medications (OR, 2.25, P < 0.001) at the time of LPI. In multivariable logistic regression analysis, African Americans were significantly more likely to be prescribed additional glaucoma medications after LPI (OR, 1.73; P = 0.025) and receive glaucoma surgery (OR, 2.7; P = 0.007), but were less likely to receive SLT (OR, 0.37; P = 0.009). In multivariate Cox proportional-hazards regression analysis, African Americans had longer time to SLT than whites (hazard ratio [HR], 0.41; P = 0.022), but a shorter time to glaucoma surgery (HR, 2.57; P = 0.004). There was no significant association between race and the likelihood of cataract surgery or time to cataract surgery (P > 0.10). CONCLUSIONS: African Americans were more likely than whites to carry a diagnosis of PAC or PACG at the time of LPI and were significantly more likely to be prescribed additional glaucoma medications and require glaucoma surgery after LPI. Improved screening methods that target African Americans with NAs are needed so that preventive interventions such as LPI can be performed earlier to decrease the risk of progression.

Risk Factors Associated with Missed Diagnoses of Narrow Angles by the Van Herick Technique.

PURPOSE: To identify which factors are associated with a deep-appearing anterior chamber on slit-lamp examination by the Van Herick (VH) technique in eyes with a diagnosis of narrow angle (NA) on gonioscopy. DESIGN: Retrospective review. PARTICIPANTS: One thousand three hundred fourteen eyes in 696 participants with NA on indirect gonioscopy. METHODS: All included eyes were graded as narrow with iridotrabecular contact on indirect gonioscopy in a darkened room by a single trained glaucoma specialist. Before gonioscopy, eyes were graded as narrow or deep by VH slit-lamp examination technique. Demographic and clinical factors predictive of a deep VH grading were assessed using logistic regression with generalized estimating equations. MAIN OUTCOME MEASURES: Factors associated with deep versus narrow VH grade. RESULTS: Using the VH technique, 13.7% of eyes (n = 180/1314) with NA on gonioscopy were classified as deep. Eyes with primary angle-closure glaucoma (PACG; odds ratio, 2.43; P < 0.001) and primary angle closure (PAC; odds ratio, 1.38; P = 0.006) were significantly more likely to be graded as deep by the VH technique relative to eyes that were primary angle-closure suspects (PACSs). In multivariate analysis, male gender (odds ratio, 2.22; P < 0.001), myopia (odds ratio, 1.4; P = 0.048), and black (odds ratio, 4.11; P < 0.001) and Asian (odds ratio, 2.24; P = 0.044) race were independent risk factors for a deep grading with the VH technique in eyes with NA on gonioscopy. CONCLUSIONS: Patients with NAs on gonioscopy who are men, myopic, and of black or Asian race are at increased risk of being misdiagnosed with deep angles if examined with the VH technique alone. Eyes with PACG and PAC may be more likely than those with PACS to be misdiagnosed as deep with the VH technique. It is possible that by being missed by the VH technique, these eyes could have progressed from PACS to PAC and PACG. Patients with these demographic and clinical characteristics in the presence of other risk factors for glaucoma should undergo careful gonioscopy.

Organizational learning in a college of nursing: A learning history.

BACKGROUND: College of nursing leaders can foster organizational learning as a means of achieving their desired organizational outcomes. Organizational learning has not previously been studied in colleges of nursing, leaving college administrators and faculty little guidance as they strive to improve outcomes in their own colleges. OBJECTIVES: The purpose of this study was to discover new insights related to organizational learning in a college of nursing. DESIGN: The learning history method was used to document and describe organizational learning in a college of nursing. SETTING: This study was conducted with a college of nursing situated in a private, religious-based university in the western United States. PARTICIPANTS: Six stakeholders and 16 individuals familiar with the college's history were purposively recruited for this study. Participants included college administrators, faculty, students, alumni, and individuals with university-level responsibilities related to the college. METHODS: Semi-structured interviews and college artifacts were used to gather data. Data was reviewed and themes identified through a process called "distillation." FINDINGS: The college's vision, "Learning the Healer's Art" provides purpose and motivation within the college. Four themes provide additional insight into how the college established a learning culture and fosters behavior conducive to organizational learning: (1) Character and Quality, (2) Long-Term Perspective, (3) Collaborative Leadership and Adaptation, and (4) Mentoring. CONCLUSION: College of nursing leaders can foster organizational learning and pursue improvement within their colleges. Recommended actions include developing a shared vision for the college, building a cadre of qualified faculty and students who have strong personal character, maintaining a long-term perspective, using a collaborative approach to leadership and adaptation, and facilitating mentoring.

Introducing a New Surgical Technology: Controversies in Femtosecond Laser-assisted Cataract Surgery and Impact on Resident Surgical Training.

Femtosecond laser-assisted cataract surgery is becoming more widely available as an option for patients considering cataract surgery. Controversies exist around determining the best platform for LCS, the potential global role and cost to the health care system of LCS, as well as the future of LCS in resident surgical training.

Refractory open-angle glaucoma after neodymium-yttrium-aluminum-garnet laser lysis of vitreous floaters.

PURPOSE: To illustrate 3 cases of chronic open-angle glaucoma secondary to the neodymium-yttrium-aluminum-garnet (Nd:YAG) laser vitreolysis procedure for symptomatic vitreous floaters. DESIGN: Observational case series. METHODS: Location of the study was the Doheny Eye Institute. Three eyes of 2 patients who developed chronic open-angle glaucoma after Nd:YAG vitreolysis for symptomatic floaters presenting with very high intraocular pressure (IOP >40 mm Hg) were selected. The time from the laser treatment to the onset of elevated pressure ranges from 1 week to 8 months. There was no associated inflammation, steroid use, or other identifiable cause of chronic IOP elevation. RESULTS: All eyes were treated initially with glaucoma medication, followed by selective laser trabeculoplasty (SLT) and eventually glaucoma surgery (Trabectome) in 2 eyes for disease management. In all eyes, intraocular pressures were eventually stabilized within a normal pressure range from 18 to 38 months following Nd:YAG vitreolysis. At the latest follow-up post surgery, all eyes had intraocular pressures of 22 mm Hg or less with or without medications. CONCLUSIONS: Secondary open-angle glaucoma is a complication of Nd:YAG vitreolysis for symptomatic floaters that may present with an increase in intraocular pressure immediately, or many months after the surgery. Furthermore this complication may be permanent and require chronic medical therapy or glaucoma surgery.

Will DNA methylation inhibitors work in solid tumors? A review of the clinical experience with azacitidine and decitabine in solid tumors.

The recent approval of azacitidine (Vidaza®), decitabine (Dacogen®) and vorinostat (Zolinza™) for myelodysplastic syndrome and cutaneous T-cell lymphoma has led to a wave of interest in epigenetic therapy. These DNA methylation inhibitors and the histone deacetylase inhibitor clearly have demonstrated activity in hematologic malignancies, but the future role of epigenetic therapy in solid tumors is still unknown. What is not commonly known is that azacitidine and decitabine were originally developed as cytotoxic nucleoside analogs and clinical trials were previously conducted in a variety of cancer types prior to the knowledge of their ability to inhibit DNA methylation. We review the experience of azacitidine and decitabine in early clinical trials and demonstrate the activity of epigenetic therapy in solid tumors.